Daily Anesthesiology Research Analysis
Three perioperative studies stand out today: a multicenter randomized trial shows single-shot intercostal nerve block is noninferior to thoracic epidural for pain after thoracoscopic lung resection while enhancing recovery; a dual-center randomized trial finds norepinephrine infusion (dose-equivalent) is as safe as phenylephrine for preventing spinal-induced hypotension in cesarean delivery with less bradycardia; and a validated multicenter machine-learning model accurately predicts death within
Summary
Three perioperative studies stand out today: a multicenter randomized trial shows single-shot intercostal nerve block is noninferior to thoracic epidural for pain after thoracoscopic lung resection while enhancing recovery; a dual-center randomized trial finds norepinephrine infusion (dose-equivalent) is as safe as phenylephrine for preventing spinal-induced hypotension in cesarean delivery with less bradycardia; and a validated multicenter machine-learning model accurately predicts death within 1 hour after terminal extubation in PICUs, informing DCDD planning and family counseling.
Research Themes
- Thoracic perioperative analgesia and enhanced recovery
- Vasopressor choice in obstetric anesthesia
- Predictive analytics for end-of-life and organ donation in critical care
Selected Articles
1. Intercostal or Paravertebral Block vs Thoracic Epidural in Lung Surgery: A Randomized Noninferiority Trial.
In a multicenter randomized trial of thoracoscopic lung resections, single-shot intercostal nerve block achieved noninferior pain control to thoracic epidural over POD0–2 while reducing opioid use and improving mobilization; length of stay was shorter with ICNB. Continuous paravertebral block was inferior to epidural for pain but also reduced opioids and enhanced mobility.
Impact: This is high-quality randomized evidence that a simpler, less invasive block can replace epidural analgesia for VATS lobectomy/segmentectomy without sacrificing pain control and with better recovery metrics.
Clinical Implications: For thoracoscopic anatomical lung resections, ICNB can be adopted as a first-line regional strategy in ERAS pathways when epidural is undesirable, balancing analgesia with fewer side effects, easier mobilization, and shorter hospitalization.
Key Findings
- ICNB was noninferior to TEA for the proportion of pain scores ≥4 on POD0–2 (upper 1-sided 98.65% CI 16.1%).
- PVB was inferior to TEA for pain (upper limit > noninferiority margin).
- ICNB and PVB reduced opioid consumption and enhanced mobilization compared with TEA.
- ICNB was associated with shorter hospital stay; QoR-15 scores were similar among groups.
Methodological Strengths
- Multicenter randomized design with both ITT and per-protocol analyses
- Predefined noninferiority margin for pain and superiority assessment for QoR; clinically relevant secondary endpoints
Limitations
- Open-label design may introduce performance bias
- Regional practice patterns and adjuncts could vary across centers; generalizability beyond VATS anatomical resections uncertain
Future Directions: Head-to-head trials of ICNB protocols (e.g., multi-level, liposomal local anesthetics), cost-effectiveness analyses, and pragmatic implementation studies across diverse thoracic procedures.
2. Death One Hour After Terminal Extubation in Children: Validation of a Machine Learning Model to Predict Cardiac Death After Withdrawal of Life-Sustaining Treatment in a Multicenter Cohort, 2009-2021.
Using multicenter retrospective data from 10 PICUs, a parsimonious extra-trees model with 21 variables predicted death within one hour after terminal extubation with AUC 0.84 and PPV 88% at 90% sensitivity, and was temporally and externally validated. Performance held among potential DCDD donors, supporting clinical logistics and counseling.
Impact: This study provides validated predictive tooling for a time-critical endpoint with direct implications for family counseling and DCDD feasibility, an area lacking robust, generalizable models.
Clinical Implications: PICUs can use such models to anticipate the likelihood of death within 1 hour post-extubation, better counsel families, align multidisciplinary teams, and streamline DCDD processes when desired.
Key Findings
- Extra-trees model (21 features) achieved AUC 0.84 (95% CI 0.81–0.87) on external temporal validation.
- At 90% sensitivity, PPV was 88%, NPV 70%, with number needed to alert 1.14.
- Among potential DCDD donors, PPV 86% and NPV 74% at the same sensitivity.
- Model trained on 8 sites (2009–2018) and validated on all 10 sites (2019–2021), supporting generalizability.
Methodological Strengths
- Multisite dataset with temporal and external validation enhancing generalizability
- Parsimonious feature set facilitating interpretability and clinical implementation with strong discrimination
Limitations
- Retrospective observational design susceptible to unmeasured confounding and documentation biases
- Model calibration and fairness across subgroups were not extensively reported; implementation and ethical frameworks are needed
Future Directions: Prospective validation with real-time integration, calibration and fairness audits, and decision-support trials to assess effects on counseling, DCDD logistics, and resource utilization.
3. Effects of Prophylactic Infusion of Equivalent Doses of Norepinephrine and Phenylephrine in Preventing Spinal Anesthesia-Induced Hypotension During Cesarean Delivery on Fetal and Maternal Outcomes: A Dual-Center, Non-Inferiority Controlled Trial.
In a dual-center randomized noninferiority trial with dose-equivalent infusions, norepinephrine (0.10 μg/kg/min) was noninferior to phenylephrine (0.60 μg/kg/min) for neonatal UA pH and had similar hypotension rates but significantly less bradycardia. Neonatal outcomes were comparable between groups.
Impact: This trial addresses dose-equivalence rigorously and supports norepinephrine as a bradycardia-sparing first-line vasopressor for spinal hypotension in cesarean delivery.
Clinical Implications: Norepinephrine infusion at dose-equivalent rates can be used to prevent spinal-induced hypotension in cesarean delivery with reduced bradycardia risk compared with phenylephrine, without compromising neonatal acid-base status.
Key Findings
- Neonatal UA pH with norepinephrine was noninferior to phenylephrine (mean difference 0.003; 95% CI -0.016 to 0.022; P=0.009).
- Maternal hypotension incidence was similar (8.3% NE vs 10.6% PE; P=0.701).
- Bradycardia was significantly less frequent with norepinephrine (2.1% vs 12.8%; P=0.046).
- Neonatal outcomes beyond UA pH were comparable between groups.
Methodological Strengths
- Randomized allocation with dose-equivalent comparison across two centers
- Clinically meaningful primary endpoint (neonatal UA pH) with predefined noninferiority framework
Limitations
- Modest sample size limits power for rare adverse events and subgroup analyses
- Short-term outcomes; no long-term maternal or neonatal follow-up
Future Directions: Larger multicenter trials with long-term follow-up and evaluation of closed-loop vasopressor titration comparing norepinephrine vs phenylephrine across diverse obstetric populations.